Provider Demographics
NPI:1366988115
Name:AMEN, GODWIN
Entity type:Individual
Prefix:
First Name:GODWIN
Middle Name:
Last Name:AMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 ASTER TRL
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-6329
Mailing Address - Country:US
Mailing Address - Phone:469-698-6617
Mailing Address - Fax:
Practice Address - Street 1:2015 ASTER TRL
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-6329
Practice Address - Country:US
Practice Address - Phone:469-698-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$OtherSSN